Evaluation of antihypertensive therapy in diabetic hypertensive patients: impact of ischemic heart disease
Macrovascular complications are common in diabetic hypertensive patients. Appropriate antihypertensive therapy and tight blood pressure control are believed to prevent or delay such complication.
Objective: To evaluate utilization patterns of antihypertensive agents and blood pressure (BP) control among diabetic hypertensive patients with and without ischemic heart disease (IHD).
Methods: Retrospective cohort study of all diabetic hypertensive patients attending Al-watani medical center from August 2006 until August 2007. Proportions of use of different antihypertensive drug classes were compared for all patients receiving 1, 2, 3, or 4 or more drugs, and separately among patients with and without IHD. Blood pressure control (equal or lower 130/80 mmHg) was compared for patients receiving no therapy, monotherapy, or combination therapy and separately among patients with and without IHD.
Results: 255 patients were included in the study; their mean age was 64.4 (SD=11.4) years. Sixty one (23.9%) of the included patients was on target BP. Over 60% of the total patients were receiving angiotensin-converting enzyme inhibitors (ACEI)/ angiotensin receptor blocker (ARB), followed by diuretics (40.8%), calcium channel blockers (25.1%) and beta-blockers (12.5%). The majority (> 55%) of patients were either on mono or no drug therapy. More than 55% of patients with controlled BP were using ACE-I. More than half (50.8%) of the patients with controlled BP were on combination therapy while 42.3% of patients with uncontrolled BP were on combination therapy (p=0.24). More patient in the IHD achieved target BP than those in non-IHD group (p=0.019). Comparison between IHD and non-IHD groups indicated no significant difference in the utilization of any drug class with ACE-I being the most commonly utilized in both groups.
Conclusions: Patterns of antihypertensive therapy were generally but not adequately consistent with international guidelines. Areas of improvement include increasing ACE-I drug combinations, decreasing the number of untreated patients, and increasing the proportion of patients with controlled BP in this population.
2. Simonson DC. Etiology and Prevalence of hypertension in diabetic patients. Diabetes Care 1988; 11(10):821-827.
3. Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, Mitch W, Smith SC Jr, Sowers JR. Diabetes and cardiovascular disease. A statement for healthcare professionals from the American Heart Association. Circulation. 1999; 100(10):1134-1146.
4. Intensive blood-glucose control with sulphonylurea or insulin compared with conventional treatment and risk of complications in patients with type-2 diabetes mellitus (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998; 352(9131):837-853.
5. Epstein M, Sowers JR. Diabetes mellitus and hypertension. Hypertension 1992 ;19(5):403-418.
6. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the multiple risk factor intervention trial. Diabetes Care, 1993;16(2):434-444.
7. Hypertension in Diabetes Study (HDS): I. Prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardiovascular and diabetic complications. J Hypertens. 1993;11(3):309-317.
8. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, Ménard J, Rahn KH, Wedel H, Westerling S. Effects of intensive blood pressure lowering and low dose aspirin in patients with hypertension: principle results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group. Lancet. 1998;351(9118):1755-1762.
9. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360(9326):23-33.
10. Chin MH, Su AW, Jin L, Nerney MP. Variations in the care of elderly persons with diabetes among endocrinologists, general internists, and geriatricians. J Gerontol A Biol Sci Med Sci. 2000;55(10):M601-606.
11. Harris MI. Health care and health status and outcomes for patients with type 2 diabetes. Diabetes Care. 2000;23(6):754-758.
12. Martin TL, Selby JV, Zhang D. Physician and patient prevention practices in NIDDM in a large urban managed-care organization. Diabetes Care. 1995;18(8):1124-1132.
13. Tuomilehto J, Rastenyte D, Birkenhäger WH, Thijs L, Antikainen R, Bulpitt CJ, Fletcher AE, Forette F, Goldhaber A, Palatini P, Sarti C, Fagard R. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic hypertension in Europe trial Investigators. N Engl J Med. 1999;340(9):677-684.
14. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
15. Al Khaja KA, Sequeira RP, Mathur VS, Damanhori AH, Abdul Wahab AW. Family physicians' and general practitioners' approaches to drug management of diabetic hypertension in primary care. J Eval Clin Pract 2002;8(1):19-30.
16. Cooke CE, Fatodu H. Physician conformity and patient adherence to ACE inhibitors and ARBs in patients with diabetes, with and without renal disease and hypertension, in a medicaid managed care organization. J Manag Care Pharm. 2006;12(8):649-655.
17. Waleed M. Sweileh, Ola A. Aker, & Nidal A. Jaradat. Pharmacological and Therapeutic analysis of anti-diabetic and antihypertensive drugs among diabetic hypertensive patients in Palestine. Journal of the Islamic University of Gaza, (Natural Sciences Series) 2004;12(2): 35-57.
18. Malini PL, Strocchi E, Fiumi N, Ambrosioni E, Ciavarella A. ACE inhibitor-induced cough in hypertensive type 2 diabetic patients. Diabetes Care. 1999;22(9):1586-1587.
19. Ishimitsu T, Yagi S, Ebihara A, Doi Y, Domae A, Shibata A. Long term evaluation of combined antihypertensive therapy with lisinopril and a thiazide diuretic in patients with essential hypertension. Japan Heart J. 1997;38(6):831-840.
20. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981-2997.
21. Bakris GL, Weir MR, DeQuattro V, McMohan FG. Effects of an ACE inhibitor/calcium antagonist combination on proteinuria in diabetic nephropathy. Kidney Int. 1998;54(4):1283-1289.
22. Velussi M, Brocco E, Frigato F, Zolli M, Muollo B, Maioli M, Carraro A, Tonolo G, Fresu P, Cernigoi AM, Fioretto P, Nosadini R. Effects of cilazapril and amlodipine on kidney function in hypertensive NIDDM patients. Diabetes. 1996;45(2):216-222.
23. Khalid AJ Al Khaja, Reginald P Sequeira and Vijay S Mathur. Prescribing pattern and therapeutic implications for diabetic hypertension in Bahrain. Ann Pharmacother. 2001;35(11):1350-1359.
24. Sequeira RP, Al Khaja KA, Damanhori AH. Evaluating the treatment of hypertension in diabetes mellitus: a need for better control? J Eval Clin Pract. 2004;10(1):107-116.
25. Westheim A, Klemetsrud T, Tretli S, Stokke HP, Olsen H. Blood pressure levels in treated hypertensive patients in general practice in Norway. Blood Press. 2001;10(1):37-42.
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